Specialist, Admin Complaints, Grievances & Appeals

Oscar Health is a health insurance company that focuses on serving its members through a technology-driven platform. The Specialist, Admin Complaints, Grievances & Appeals will manage and resolve complex administrative grievances and appeals, ensuring compliance with regulatory standards and championing member satisfaction.

Responsibilities

• Follow established workflows to acknowledge, log, and perform initial triage on complex or escalated administrative grievances from members and/or providers
• Conduct thorough, multi-faceted investigations by gathering and analyzing internal data, call logs, correspondence, etc
• Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to accurately determine the root cause of member and/or provider issues
• Liaise with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case resolution
• Based on investigative findings, determine a resolution strategy that is both fair and compliant with company and regulatory guidelines, utilizing established workflows
• Escalate the issue to leadership for further guidance on resolution strategy, as needed
• Draft clear, accurate, complete resolution letters, ensuring all required regulatory elements are included
• Maintain meticulous and comprehensive case files in the case management system to ensure a clear and complete audit trail for each case
• Monitor and manage case timelines to ensure strict adherence to all federal and state mandated deadlines
• Compliance with all applicable laws and regulations
• Other duties as assigned

Skills

• 1+ years of professional experience in a regulated industry, such as healthcare, insurance
• 1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, and final documentation, while meeting competing priorities
• 1+ years of experience with directly managing escalated customer, member or provider cases
• 1+ years of experience with drafting and issuing formal written communication to member or providers
• 1+ years of experience working in a highly structured, workflow driven, environment
• Bilingual in Spanish (reading and writing)
• Bachelor's degree
• Experience in health care administration
• Involvement in departmental or cross-functional process improvement or quality initiatives

Benefits

• Medical, dental, and vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements

Company Overview

Company H1B Sponsorship